Can a medical aid scheme exclude a pre-existing health condition?

So you’ve finally decided to get onto a private medical aid scheme. You figure if you get ill, you can’t run the risk of landing up in a government hospital. The problem is you aren’t 100% fighting fit anymore! Your back keeps playing up since that unfortunate mountain bike crash and you’ve developed hypertension. Is this going to be a problem when applying to become a new member of a private medical aid scheme?

In my last medical aid post I dealt with the 1st waiting period a medical aid scheme can impose on new members. I’ll provide the link to that blog post at the end of this article. Today I’m going to deal with the 2nd waiting period a medical aid scheme can slap you with, once your application’s been submitted.

It’s called a “condition-specific-waiting period” and this is what you need to know…

If you haven’t belonged to a registered South African medical aid scheme before, or you’ve allowed yourself a 90 day break since resigning from your previous medical aid scheme, the scheme you are applying to join can impose a 12-month-condition-specific-waiting period.

So what is a 12- month-condition-specific-waiting period?

It’s pretty simple. Any pre-existing health condition you have will be excluded for the first year of your membership. That means any medical costs associated with that excluded condition isn’t going to be paid by the scheme in the first year of your membership. Before your membership is activated, the scheme will highlight which conditions are going to be excluded and you will need to sign off an agreement.

Why would a medical aid scheme impose a waiting period like this?

It’s to protect the current membership pool. Imagine for a second they didn’t have a protective measure like this in place. Anyone needing costly triple bypass surgery could jump onto a scheme and hit them for a whack of cash in the first week of being a member. Then they could simply leave the scheme.

When else can a scheme impose the condition-specific-waiting period?

If you’ve belonged to a scheme for less than two years, a scheme can also impose the condition-specific waiting period but they need to cover Prescribed Minimum Benefits. If you’ve never heard the term Prescribed Minimum Benefits or PMB’s, check out my blog post. I’ll provide the link at the end of the article.

What happens if I leave a scheme to join a new scheme and I’m not yet through the condition-specific-waiting period?

That’s a good question. If your previous medical aid scheme placed a condition-specific-waiting-period on your membership and the waiting period didn’t expire at the date of ending your membership, the new scheme will make you wait out the remainder of the waiting period.

Remember you can Get Medical Aid Insurance at Insurance Fundi. Medical Aid cover is important insurance, so don’t delay getting onto a scheme today.

Until next time.

The InsuranceFundi Team

8 Comments

Jo
on 23 March 2011 at 10:54

Hi Brendan.

I am almost 25 years old and have been off medical aid since I was booted from my parents medical aid at the age of 21. I therefore have a list of things that have gone untreated for the last 4 years. For example, I know I will need fillings, and I have a stomach ulcer that is in desperate need of a scope. I also take monthly medication for this. I have therefore been trying to find a plan that will cover the ulcer treatment specifically.

After reading your blog I now realise that I will face a one year waiting period before I can go for the scope or have the medical aid pay for my medication. Please tell me, under what obligation am I to tell the medical aid about my ulcer? Also, what counts as a pre-existing condition? Does the fact that I know I will need fillings count as a pre-existing condition or is it only conditions that I have been treated for in the past?

Thanks for your comment. At application stage you are obliged to let your
new medical aid scheme know about any pre-existing conditions no matter how
small or insignificant they might seem (fillings for teeth). What counts as
a pre-existing condition? Unfortunately any health condition that was
pre-existing before applying to join the scheme. From the schemes
perspective, they want to make sure you aren’t going to hop onto the medical
aid with conditions, claim and leave.

I realize this article is several years old now, but I have a question: What about a person from outside SA who settles in the country but has a pre-existing condition? If they had medical insurance in their previous country, would that be recognized for the purpose of determining exclusions? Also, is BUPA considered a “South African registered medical aid scheme?”

Your pre-existing condition will be excluded for up to a year regardless of SA citizenship.
Previous medical aid membership in a foreign country is not recognised in South Africa so exclusions and late joiner penalties will apply.
BUPA is not recognised as a SA registered medical scheme as far as we know.

In August this year I had problem with my knee, it locked. Went to general doctor, he told me it might be a torn knee cartilage or it might just go away on it’s own. Went for xrays the next day just to make sure, but nothing looked wrong on it. After using the anti inflammatories it seemed to have healed, and left it there. Start of October my fiance decided that it’s time to add me as a dependant on his medical aid, that is suppose to kick in December. I did mention this in my application form. But yesterday I twisted my knee when I slipped on a step. Obviously it was swollen, so I decided to go see a orthopeadist as I suspected the previous doctor will just tell me the same as last. He told me that it was indeed a torn knee cartilage and will definitely need a small opp to fix it. How does it work now ? I didn’t know of the problem as it seemed to heel itself before we applied to add me.
Regards

As long as you mentioned your knee problem on your application form then it should be covered. Just make sure that no waiting period was applied to your membership.
Occasionally, if there is a pre-existing condition, they could impose up to a 12 month waiting period before allowing claims for that condition.